Salutation*
Mr.Mrs.Ms.Dr.Prof.
First Name*
Last Name*
Date of Birth*
Registering for a child?*
YesNo
Email*
Home Phone
Cell Phone*
Work Phone
Address*
Street Address
City
Province
Postal Code
Name*
Relation*
I prefer appointment reminders by*
PhoneSMS (TEXT)Email
Whom may we thank for referring you?
GoogleFacebookInstagramTiktokReferred By
Are any other members of your family patients at our practice?*
Yes, insurance applies to meNo, insurance does not apply to me
Does secondary insurance apply to me?*
The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by Doctor/Patient confidentiality. The Dentist will review the questions and explain any that you do not understand. Please complete the entire form.
Are you being treated for any medical condition at the present or any time within the past year?*
YesNoNot Sure/Maybe
When was your last medical checkup?*
Has there been any change in your general health in the past year?*
Are you taking any prescription, non-prescription medications, or herbal supplements?*
Do you have any allergies?*
Have you ever had a peculiar or adverse reaction to any medicines or injections?*
Do you have or have you ever had asthma?*
Do you have or have you ever had any heart or blood pressure problems?*
Do you have or have you ever had an artificial heart valve, infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease), or a heart transplant?*
Do you have a prosthetic or artificial joint?*
Have you ever been advised by a medical professional that you require a prophylactic antibiotic prior to dental treatment?*
Do you have any conditions which may affect your immune system (i.e. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?*
Have you ever had hepatitis, jaundice, or liver disease?*
Do you have a bleeding problem or bleeding disorder?*
Have you ever been hospitalized for any illnesses or operations?*
Do you have, or have ever had any of the following? Please check*
Chest pain/anginaOsteoporosis MedicationsMitral Valve ProlapseShortness of BreathRheumatic FeverHeart AttackStrokeCancerPacemakerLung DiseaseHeart MurmurArthritisSteroid TherapyDiabetesTuberculosisDrug/Alcohol DependencySeizuresThyroid DiseaseStomach UlcersKidney DiseaseNone of the above
Are there any conditions/diseases not listed that you have or have had?*
Are there any diseases/medical problems that run in your family (e.g. diabetes, cancer, heart disease, etc.)?*
Do you smoke or chew tobacco products?*
Do you consume recreational drugs?*
Are you nervous during dental treatment?*
For women only: Are you pregnant or breastfeeding?
Do you have any specific dental concerns? Please list:
When was your last dental appointment?*
How often do you see the dentist?*
Not ApplicableEvery 3 monthsEvery 4 monthsEvery 6 monthsOnly when something is bothering me
Is there anything about the appearance of your teeth that you would like to change?
Have you ever whitened (bleached) your teeth?
Do you feel uncomfortable or self-conscious about the appearance of your teeth?
Have you been disappointed with the appearance of previous dental work?